One solution to hallway medicine: outpatient hip-replacements

TheStar.com – News/GTA
Oct. 4, 2018.   By

Kaori Noguchi recalls being taken aback when her surgeon’s office called to book her hip replacement surgery.

She was told she could have the operation as an outpatient, meaning she would be in and out of hospital the same day.

Thirty years ago, this procedure would have required a hospital stay of up to seven days, and more recently it’s taken an average of three days.

“Initially I was a bit freaked out,” Noguchi said, explaining that she was concerned she would be in too much pain and not mobile enough to leave the hospital so soon.

But on Monday she did just that. The 47-year-old Toronto resident left Women’s College Hospital just after 4 p.m. — only four hours after being wheeled out of the operating room and eight hours after arriving at the hospital.

Women’s College is the only fully ambulatory hospital in Ontario, meaning it has no overnight beds. It describes itself as “a hospital designed to keep people out of hospital.”

Part of its mission is to help improve the broader health system. One way it’s trying to do that is by spreading the word about the advantages of ambulatory, or outpatient, surgery.

Surgeon-in-chief Dr. David Urbach said doing more joint-replacements this way could take significant pressure off the entire hospital system.

“This approach, applied throughout the province, has the potential to save a huge amount of money and free up many beds in the Ontario hospital system,” he said.

According to data from the hospital, approximately 50,000 hip and knee replacements are done annually in Ontario. The average hospital stay is three days.

If 50 per cent were done on an outpatient basis, that would free up 75,000 days of hospital beds annually. That would be the equivalent of opening up a new 200-bed hospital.

The savings would amount to more than $100 million annually.

“What we are advocating is to transform up to half of all total joint operations into same-day discharge ambulatory procedures, without patients entering a hospital ward at all,” Urbach said.

Women’s College rolled out a similar program for knee replacements earlier this year.

Anthony Dale, president of the Ontario Hospital Association, said solutions like this are needed to address hospital overcrowding.

“This work at Women’s College Hospital is a great example of the kind of innovation that’s needed to end hallway health care,” he said, referring to the phenomenon of hospitals being so crowded that patients are cared for in corridors.

Though Women’s College is not the first hospital in Ontario to do ambulatory hip-replacements, this kind of surgery is “not widespread at all,” Dale noted. “The fact you can have it done in a single day … that’s pretty powerful.”

Urbach estimates fewer than 100 total joint replacements, without overnight hospital admissions, were done in the province prior to this year.

Ambulatory hip-replacement surgery was pioneered in Chicago in the early 2000s, explained Dr. John Antoniou, president of the Canadian Orthopaedic Association, adding today it is done with much more regularity south of the border.

He acknowledged some patients might be uncomfortable with the idea of leaving the hospital so soon and said initiatives such as the one at Women’s College “help make it more socially acceptable.”

Noguchi said she came around to being OK with the idea of ambulatory surgery after her doctors explained how it worked and shared with her media stories about others getting it.

She is the fourth patient at Women’s College to undergo outpatient hip replacement surgery in the last month.

Noguchi has hip dysplasia, a condition that has resulted in painful arthritis and causes her to limp.

In recent years, the pain has become so bad it interrupts her sleep. It has also forced her to switch to a desk job in her field of event and catering management. It hurts when she is on her feet for too long.

The way the actual surgery is done is no different for outpatients than for those with longer hospital stays. What is different is the anesthesia and aftercare.

“What we have done is develop a virtual care pathway that makes same-day total joint replacement routine for many patients,” Urbach explained.

Ultra short-acting spinal and regional anesthesia is used instead of general anesthesia. That shortens recovery time and allows patients to walk comfortably immediately after surgery.

“We add additional resources to replicate the in-hospital post-op care experience,” Urbach added.

That includes a virtual care app, developed by the hospital, which allows patients to keep in touch with their care teams.

“The app replicates the experience you would have as a surgeon seeing your patient in hospital. You can look at them face to face, you can answer questions, you can see if they are in pain, you can see how they are doing,” he said.

As well, remote monitoring devices are used, including step counters.

“Many patients probably have enhanced exposure to their care team,” Urbach said. “Doctors and nurses can connect with them using mobile devices instead of rushing to see them in hospital wards.”

Dr. Paul Kuzyk, one of two orthopedic surgeons who operated on Noguchi, explained that not all patients who need hip replacements are candidates for day surgery. It works best on those who are otherwise healthy, highly motivated and have loved ones at home to help them recover.

The surgery itself took less than two hours. Noguchi was out of it for the most part, awakening only briefly to the noise generated by orthopedic surgery tools.

She was oblivious to what was happening below the surgical drape and assured the anesthesia assistant she was comfortable.

After Kuzyk removed the femoral head — the “ball” part of the ball-and-socket hip joint — he pointed out where it had been damaged by arthritis. Cartilage was visibly worn away from the surface.

Kuzyk and fellow surgeon, Dr. Oleg Safir, replaced Noguchi’s hip with ceramic, plastic and titanium parts. Their work was physically demanding.

Safir explained stays were longer in the past because hospitals wanted to ensure patients did not suffer from post-surgical complications.

As stays have shortened, complication rates have been closely monitored. They have not increased, Safir said.

Urbach said outcomes are excellent and patients recover just as well with ambulatory surgery.

“Being able to discharge a patient on the day of surgery means the patient has to be completely comfortable, mobile, stable and confident,” he said. “We ensure patients feel so good after surgery that they are not afraid of going home.”

Patients benefit by recovering in the comfort and familiarity of their own homes, Urbach noted. Shorter stays reduce the risk of picking up a hospital-acquired infection or developing hospital-acquired delirium, he added.

Less than three hours after her surgery, Noguchi was on her feet. She tested out her new hip, walking down the hospital corridor with the aid of a walker.

Physiotherapist Hari Nair then guided her as she climbed a staircase, using a cane.

Noguchi said she was in no discomfort. She was on painkillers and given a prescription so she could continue taking them at home.

“It’s pretty amazing how they can do this operation as and in-and-out surgery,” she exclaimed. “I’m feeling good. I’m ready to go.”

Theresa Boyle is a Toronto-based reporter covering health. Follow her on Twitter: @theresaboyle

https://www.thestar.com/news/gta/2018/10/04/one-solution-to-hallway-medicine-outpatient-hip-replacements.html

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